Bedside ultrasound to detect central venous catheter misplacement and associated iatrogenic complications: a systematic review and meta-analysis

Abstract

Background: Insertion of a central venous catheter (CVC) is common practice in critical care medicine. Complications arising from CVC placement are mostly due to a pneumothorax or malposition. Correct position is currently confirmed by chest x-ray, while ultrasonography might be a more suitable option. We performed a meta-analysis of the available studies with the primary aim of synthesizing information regarding detection of CVC-related complications and misplacement using ultrasound (US).

Methods: This is a systematic review and meta-analysis registered at PROSPERO (CRD42016050698). PubMed, EMBASE, the Cochrane Database of Systematic Reviews, and the Cochrane Central Register of Controlled Trials were searched. Articles which reported the diagnostic accuracy of US in detecting the position of CVCs and the mechanical complications associated with insertion were included. Primary outcomes were specificity and sensitivity of US. Secondary outcomes included prevalence of malposition and pneumothorax, feasibility of US examination, and time to perform and interpret both US and chest x-ray. A qualitative assessment was performed using the QUADAS-2 tool.

Results: We included 25 studies with a total of 2548 patients and 2602 CVC placements. Analysis yielded a pooled specificity of 98.9 (95% confidence interval (CI): 97.8-99.5) and sensitivity of 68.2 (95% CI: 54.4-79.4). US examination was feasible in 96.8% of the cases. The prevalence of CVC malposition and pneumothorax was 6.8% and 1.1%, respectively. The mean time for US performance was 2.83 min (95% CI: 2.77-2.89 min) min, while chest x-ray performance took 34.7 min (95% CI: 32.6-36.7 min). US was feasible in 97%. Further analyses were performed by defining subgroups based on the different utilized US protocols and on intra-atrial and extra-atrial misplacement. Vascular US combined with transthoracic echocardiography was most accurate.

Conclusions: US is an accurate and feasible diagnostic modality to detect CVC malposition and iatrogenic pneumothorax. Advantages of US over chest x-ray are that it can be performed faster and does not subject patients to radiation. Vascular US combined with transthoracic echocardiography is advised. However, the results need to be interpreted with caution since included studies were often underpowered and had methodological limitations. A large multicenter study investigating optimal US protocol, among other things, is needed.

Keywords: CVC malposition; Central venous catheter; Chest x-ray; Iatrogenic complications; Meta-analysis; Pneumothorax; Ultrasound.

Fig. 1

PRISMA flow diagram of search strategy and study selection. Depicted in the flow diagram are the number of identified records, the number of screened records, the number of articles assessed for eligibility with reasons for exclusion, and the number of studies included in the qualitative and quantitative syntheses

Fig. 2

Deek’s funnel plot asymmetry test for all 25 studies. The risk of bias when all 25 studies are included in Deek’s funnel plot asymmetry test (p = 0.91). ESS effective sample size

Fig. 3

Deek’s funnel plot asymmetry test for 18 studies in which both specificity and sensitivity could be estimated. The risk of bias when only the 18 studies are included in Deek’s funnel plot asymmetry test for which both sensitivity and specificity could be estimated (p = 0.37). ESS effective sample size

Fig. 4

Forest plot of the specificity and sensitivity of ultrasound for detection of CVC-related complications. The pooled specificity and sensitivity as well as the specificity and sensitivity for each study individually with their respective confidence interval (CI). Studies showed significant statistical heterogeneity; for specificity, I² = 83.3 (95% CI: 64.6–86.7) and, for sensitivity, I² = 75.5 (95% CI: 77.1–90.4)

Fig. 5

Forest plot for the specificity and sensitivity of ultrasound for detection of CVC-related complications distinguishing between intra- and extra-atrial malposition. The pooled specificity and sensitivity for intra- and extra-atrial malposition, and the specificity and sensitivity for each study individually. CI confidence interval